in medical school, and it has the potential to improve the health of the public. i wouldn't even be here, or it would take me a longer time. the earlier, the better. you know, i was able to catch it in a stage that-you know, i'm not a long time user, but i am a user, so it was able to help me balance myself out and get myself into the help that i needed. i see many patients at the end stage of their disease, not only from their alcohol and substance use longstanding, but also from the co-occurring illnesses, which can result as, from, substance use. and so it's become vital to me, not only as a clinician but also as an educator, to really promote prevention, to allow us to identify patients before they really have reached these end-stage processes in their disease. and so, bringing these prevention techniques and early identification techniques to the residents, i feel, will only improve the health care of patients long term. so kristen, we had mentioned before the whole issue of

peer-to-peer interventions. can you talk to us a little bit, and how does that work? there are a variety of ways that we can utilize the information, the expertise of peers to help each other. there's peer mentoring, there's peer mediation, there're a variety of different things that we can do. with peer mediation, we work with youth to help each other resolve conflict, which is a tremendously useful thing in this day and age because there are so many opportunities for youth to be in conflict, not just in person now, but digitally. we want to give them as many ways to resolve those conflicts as possible. what kind of things go on digitally today? oh, my gosh. intimidate each other? we are only just beginning to even get a handle on everything, it's exploding so quickly. the common ways that they interact in a negative way, we'll say, that everyone kind of knows about, are things like facebook and twitter and texting and things like that.

but there are a variety of other platforms online where youth are interacting that adults are only just becoming really aware of. such as? even things like instagram. you know, they can even have negative interactions with instagram. so, the key thing for parents to know with all of that, well really, there are two main things i would tell parents. one is to document things. the thing that teens don't often realize with digital harassment or bullying is that a lot of it can be documented. you can screen capture a mean text, or a harassing text. you can screen capture things that happen on facebook. the other thing that i would advise parents to work with their teens on is to limit how they're interacting on social media. use their privacy settings on facebook. make sure that only the people that should see something are seeing it. a lot of teens are still making their profiles completely public on facebook, so that any adult can go on and see

them, see where they're posting, see what their whereabouts are. it's a huge safety issue. so, the first thing, as parents are allowing their kids to become active on the internet, that they should do is first teach them about the safety issues and make sure that they're using privacy settings appropriately. so, if a parent buys a young person, for safety reasons, an electronic device, i mean, they should really be monitoring this. absolutely. i would call it "age-appropriate monitoring"- yes. yes. which means like the younger, the more vigilant that they have to be. absolutely. but, i really think that as a society, we tend to taper off our vigilance a little too early. we see great leaps in issues around the middle school age, and it's partly because of the natural changes that youth undergo in middle school, but it's also because parents tend to back off a little bit in situations where maybe they shouldn't.

and pierluigi, that is where your peer mentoring and your peer support programs come in, correct? because they can actually take a look at that, and the youth are trained to detect, correct? correct. and we actually have three different levels of peer mentoring. we have in our prevention program, we have a specific suicide prevention training, with sources of strength, where we are training middle and high school students to become suicide prevention peer mentors in their schools and to be known to other students, in case those students have a question about suicide, they prefer to go to someone their own age or communicate in a way that they are more familiar. then, we have our prevention peer mentors, and these are youth that have gone through our traditional after-school prevention programs, like, "too good for drugs and violence," or our own bilingual curriculum, that samhsa named as

an exemplary program. and those youth are meeting at least on a monthly basis, and they're developing public service announcements, media campaigns, texting campaigns to reach other latino youth and to help them avoid alcohol, drugs, gangs, and those things. and then our treatment peer mentors is our latest program. we have a clubhouse model, where we have substance abuse treatment for adolescents, and we provide support services after school: tutoring, life skills, and so on. we help kids finish school, get out of gangs, stop using drugs, and graduates of that program we are hiring-paid positions-hiring as peer mentors, so they can help the new members coming in get acclimated... so, they're peer recovery young people. correct. well, that's excellent. that's excellent. does that mirror anything we're doing in the mental health side, gail?

well, i couldn't help but, first of all, applaud you for the work you're doing. and also to think about our garrett lee smith youth suicide prevention program has a variety of facets, and one program-subprogram-is we work with college campuses. and we're doing the same thing, for example, in training resident advisors in the dorm about signs of suicide. and that's who funds us is the garrett lee smith program. oh, i'm so glad to hear that! so, thank you. yes, you're very welcome. this is a wonderful way to meet you. we also work with states and travel communities, and it's the same idea: helping people within the social sphere where people, where youth, reside, to know the signs of suicide and then try refer them for help. you're a wonderful example. thank you. thank you. and richard, let's talk about a little bit about integrated care. does part of the training that you give, does it provide the whole notion of the continuity of care throughout the lifecycle of an individual who may come into that system and follow up?

yeah. so, our health educators in primary care settings, they are trained to take care of everyone from ages 10 and up with these behavioral issues. and not only are they focusing on alcohol, drugs, and mental health, but they're also focusing on tobacco, diet, exercise, and weight issues, so that we avoid them taking on some of the stigma that unfortunately the mental health treatment system, the alcohol and drug treatment system takes on. and one of our clinics, when we got started, we really just focused on alcohol and drugs, and the health educator at that clinic got to be known as the "alcohol lady." and we realized- "no, this is going the wrong way." so when we expand and cover a wider scope of behavioral risks throughout the age spectrum, then these health educators get to be known as "general health resources," and then the patient doesn't have to feel awkward when they walk into the room and, you know, "did anybody see me?" but i tell you, it's much easier to walk into the room of a health educator in your family doctor's office or

your pediatrician's office than it is to go, maybe, across town and run the risk of being seen walking into a treatment program. oh, because of the discriminatory fears. yeah, and the stigma, "who's gonna know?" and as you were saying, you know, all it takes is one twitter message and everybody at school knows. so yeah, the more we can bring these services into places where teens already feel comfortable, whether it's school or their doctor's office, where they go for a sore throat or sprained ankle, i think the more participation we'll have. and also, we need to also be keenly aware that because of the new health care reform and what it's going to offer, in terms of that whole integrated care, correct? yeah, it's very exciting that part of health care reform that many people don't know about is a strengthening of some of the enforcement of previous mental health parity bills, so we're going to see many more people now have access to services. we also see strengthening of requirements for

reimbursement for some of these screening and intervention services that in the past were largely unreimbursed, and we had to just depend on the altruism of the health care practitioners to implement these services. which, pierluigi, will certainly help you out, correct? and what should nonprofits be looking at, in terms of this new opportunity? well, one of the things that we are currently looking at is how are we going to partner to bring a primary health clinic to our agency that already sees over 600 families per week for behavioral health services. all of these families need primary care services, so having them all under one roof will not only guaranty continuity of those services, but it will guarantee a bigger prevention of physical health. for example, obesity, smoking, diabetes, all of those illnesses, along with mental health and substance abuse prevention and promotion, belong in the same roof,

under the same roof. well, i think that certainly that will go a long ways, not only in looking at that, what we call a recovery-oriented system of care- correct. for that community? correct. and are you going to partner with a hospital, or are you partnering with a health care provider? we have two different options. one of them is to partner with someone, so we're currently speaking with some partners-a physician, a pediatrician. or, we can do it ourselves, and just have someone- you want to bring it in-house. that's another option for programs. again, our communities are recently-arrived immigrant communities, and once we have their trust, they will continue to come back. we have their trust. so, for me to install a primary health clinic right where we are located will guarantee the flow of patients. absolutely. well, when we come back, we're going to talk more about additional efforts. we'll be right back. [music]

every day, i seek a positive direction for my life through my accomplishments. and now, with help and support from my family and others, i own- i own- i own my recovery from addiction and depression. join the voices for recovery. it's worth it. for information on mental and substance use disorders, including prevention and treatment referral, call 1-800-662-help. brought to you by the u.s. department of health and human services. [music]

westfield high school is located on the western part of the county by the dulles airport area in chantilly, virginia. we have approximately 2,750 students here. we do have a student services department here at westfield. it comprises of these school counselors. we have a school psychologist and school social worker. i kind of look at the counselors as always being the first line of defense. they want to make sure that kids in this school succeed, and they want to make sure you do your best at all things, even if they have to push you a little bit. what we try to do is be proactive, rather than reactionary. we sit down and talk every year about our programs and

what we do here, to try to see how can we sort of more get ahead of the issues, rather than just reacting to 'em. some common issues that students face is peer pressure, especially with drugs and alcohol and all those things. and i think for mental health, it's more of a "we don't talk about it" mentality. it's hard to kinda be open about it, 'cause you don't want to alienate yourself. the earlier you catch it, in most cases, the more treatable it is. so, you're not just preventing, you know, more of the suffering if you catch it early, but you're actually going to have better success with treatment. so they need to catch these warning signs early and get them help and see what's okay, if they're going to be okay in the long run. the program that we use for our depression awareness program this year was the sos, or signs of suicide program, that's written for high school-age students. it really focused on the students and what they can do. there's a little smirk factor on it, you know? high school kids are prone to smirk at things. but this one was really well done.

they played out scenarios and there was information about depression, information about suicide, so it was partly to introduce our screening tool, but also it was an education program. and they showed new things because they never talk about the depression stages and how to catch depression and what you need to help. so, it showed me new ways of how to get help and, you know, the ways you can, and how to help other people. after the video, we took a survey, and that survey was completely private. you did it individually, and then they took it and they gave it to the counselors. the counselors all got together and went around to all the different classrooms and collected the materials, and then took them down to a central location where there was a bunch of counselors, a director of student services, a psychologist, social workers. and people were sorting them based on answering questions whether we needed to see them that day, that week, that month. we stirred up a lot of kids that probably wouldn't have come

up on our radar before, and some had really significant issues, some fairly scary scenarios. a lot of kids got help. we gave a lot of resources out. a lot of students got to, you know, get it off their chests, whether it's true depression or just screaming for help, at least they got to be heard, they got to talk about it. they gave us this paper with all the numbers and hotlines you could call. they show you how to, what website you can go to, the people you can talk to, and at school we have a counselor, and all the teachers are pretty friendly. it tells me more about how to get help for my friends and myself. it was definitely a big help, 'cause it showed me that i could go to my counselor and talk to them if i needed to, or my parents, or any adult that i really, really trust. three months later, i had a student come to me in the cafeteria concerned about a friend and saying that they had remembered some of the concepts that were from that day and knew that they had to go talk to a trusted adult. our hope in the future, with expanding our program, is to try to infuse it throughout the school year,

so then the students will know that it's a topic that they can talk about and be comfortable to talk about with a trusted adult. and that's what our hope is to do in the future with programming. richard, you certainly work at the future wita university ths keenly engaged in helping to train individuals to do prevention, early intervention, so on and so forth, for behavioral health issues. what about those other physicians that are still providing services and have not put on the cap of integrated services? what would you say to them and where could they go for making sure that they know how to best treat their patients? well, there's lots of educational opportunities. and it's interesting, there's actually studies that show that most physicians choose to be further educated on topics that they're already familiar with, to deepen their understanding and their specialty expertise, whereas

this field calls on people to kind of come out of their usual areas of expertise and get involved with something new. so, there's lots of opportunities to come learn, but so often it's-before that, people decided that this is a gap in their practice. they've decided, "wow, especially for kids, these behavioral issues are the number one health threats for them. so maybe, rather than learning a little bit more on cholesterol issues or infectious disease, gee, let's figure out what we can do in our practice to address these number one risks that kids have." a lot of people don't really conceptualize addiction this way, for example, but addiction is basically a pediatric illness. it starts when kids are in their teens and blossoms more when they're adults and is responsible for tremendous loss of life, tremendous loss of years of life. and i just hope we can sway more health care professionals in general to pay attention to the behavioral realm.

it's responsible for 40 percent of deaths in our country, and clearly it's not getting 40 percent of attention and training. and not to mention the cost to society for all the addiction problems. absolutely. pierluigi, do you get an opportunity to train some of the physicians that are not within your clinic or working within your clinic? do you talk to the medical society or-? well, one of the areas that we've been lucky enough to be able to address is the culture and language barriers that occurs when we're addressing substance abuse and mental health issues. and yes, we have had the opportunity to speak with the family physicians and other pediatricians and general physicians in georgia. as to how do you address this in general, but also how do you address this for the growing immigrant communities that every state is facing, including georgia. we also had the opportunity to talk, not only physicians and pediatricians, but other

professionals in other areas that are present when we're dealing with our population. that includes juvenile justice, the school system, other professionals that will have interaction with youth that may not be aware as to what is needed. so, we have had georgia conferences, and we're lucky that we have the georgia school of addiction studies every year in georgia, where we're able to attract a lot of professionals, counselors, and preventionists to the conference to be able to educate 'em. yeah, i did want to bring up asam because they can always go to asam. asam, the american society for addiction medicine, has tremendous number of treatment trainings, correct? yeah, they have- they don't necessarily have to specialize, but they can become more aware. yeah, they offer a 1-week course, which can move people from novices to real experts.

another way to get excellent training is to seek out a course on motivational interviewing. motivational interviewing is a very empathic, respectful, collaborative approach, where rather than sort of the old-style physician says, "hey, you better not do that. you could die," this and so forth, that rarely changes behaviors, especially in teens who resist that kind of authority. but with motivational interviewing, we help kids take stock, "gee, you know, first of all, we acknowledge there might be some things you like about this." but, "gee, are there any fears that you have? have there been any downsides?" and then we get kids to think about, well, what's important in their lives, and how does their drinking and drug use really fit in. and many kids will take stock and, "you know, maybe i could have just as much fun if i drank a little less or avoided using that drug or stayed away from those kids who are engaged in riskier behaviors." the key is helping kids decide for themselves that they want to make a change, rather than telling them, and that's what motivational interviewing does.

it's a wonderful thing for physicians to get trained in. excellent. and speaking of motivational interviewing, in your program, kristen, how do you get youth engaged in and how do you keep them motivated? right. well, one of my favorite things that we've come up with in the last couple of years is our teen handbook. we became aware, through all of the work that we do in the community, that one of the biggest challenges that families face and that teens face is figuring out, "if there is a problem, what do i do next? how do i even access the kinds of help that i need?" so, we developed this teen handbook that walks them through step by step, so that first, they can find out, "okay, well am i even dealing with something that's unusual, or is this sort of just what teens typically go through?" so, there's basically an introduction to all kinds of issues that teens face, from eating disorders to asperger's-like behaviors, all the things that they may

have never really heard the actual terms for, or they don't really know if it's typical, or they're different. and then from there, we say, okay, well if you've identified that you maybe need some help or you want to talk to somebody, here are the people in your community you can talk to, and then if you really need a formal assessment-and we're obviously, this is for parents more that we're gearing it toward-if you need a formal assessment, here's how that process works, and here's what you can expect, here's how to navigate your insurance through this process, here're some typical obstacles. i work with a lot of school personnel and parents on, "how on earth do i get through the insurance process?" it's almost prohibitive for a lot of families; it's just so much. they're working, they have so much on their plate already, and then to be calling 20, 40 potential therapists or psychiatrists and then figuring out how to pay for it, it's just too much for a lot of families. it's quite daunting. yeah. so, we put it all together in this one handbook, and then we also go out and do presentations based on that

handbook to give people that information. when we talk about youth, how do we know and how do we assess if and when they're ready to really take on a peer role? because i think that's very important; not all youth are going to be ready. i think that for us in the prevention side, the way we recruit is either through referrals from some teachers that said, "you know, this would be a good candidate," but also how they respond, how the youth responds to the offer, how the youth contributes to what it is that it needs to be done. we give them empowerment so they can develop their style. so, there's a job description-if you will-but they can develop their style, and depending on the energy that goes into that, and how they respond to it, then they become candidates. for the treatment peers, the ones that have completed the program, of course we look at how they did in the program, but also we wait for them to make, to take the first step.

we let them know there is candidates, there is these positions that are open. but, i think that youth, being empowered- so, they self-identify? exactly. they see themselves in that position, and to us, that's one of the most valuable tools. well, it shows, it depicts leadership- that's right. and desire. gail. i was just thinking: the center for mental health services has been a national leader in developing what's called youth m.o.v.e. to really help youth become national leaders, to help others take away the stigma of asking for help or being in treatment. and we're very proud of that, and we think that's a growing trend. it is. and we can all work together on that, i think. that's a great program. yes. i'm going to ask the entire panel now: if you were looking at a crystal ball, what would be your one area where you think that we need to improve?

given everything that society is facing and given the challenges, the fiscal challenges, that we have, where should we be going in the future? kristen, i'm going to start with you. i really think we have to look at prevention and treatment as the investments that they are. i think too often, we wait until there's a national crisis, and then we spring to action. and, i think it's more important that we look at working with kids at the very earliest stages of showing that there's a problem, whether it's potential substance abuse or aggression or anxiety, which is a huge, huge problem, and that we intervene as soon as possible, and that we don't wait until a crisis happens. richard. well, i'll focus on general health care and i think where things really need to go, and they're already moving in that direction, is a much greater emphasis on these behavioral health determinants. it's, you know, we spend so much time doing physical exams and lab tests and working with patients around

cholesterol, blood pressure, all these numbers, but actually things like tobacco use and alcohol use are actually much stronger determinants of health and premature mortality. and so, either we need physicians to be able to shift in that direction, and in many settings we need to expand the health care team, so there's folks who really can dwell on those issues. to make that happen, of course, there needs to be appropriate financing of services. we can't ask clinics to just take this on out of their own generosity. they can't lose money doing this. so right now, the next, biggest thing that has to happen is medicare, which is already willing to reimburse these services when they're provided by physicians, needs also to be able to reimburse them when they're provided by health educators and other paraprofessionals who are working under the supervision of physicians. and they can take much more time, they can become much more skilled at motivational interviewing over time, so we really can have the same kind of expertise on behavioral health issues in general health care settings as

we have on cholesterol, blood pressure, diabetes, etc. very good; pierluigi? thank you. i think i would begin by saying we need to continue to think outside the box. we need to get tech savvy, we need to meet the youth at their level. we need to provide support services. you know, we have youth that get into these situations many times because they don't have that kind of support at home or in their communities. the examples i've given for georgia is, we have been blessed with a lot of support from our department of behavioral health, where they are helping us with these clubhouse models to be able to provide those support services and develop these peer models. we also need to stop confusing children, and we need to develop the tools for adults and other peers to correct the misinformation. gail? well, if i had a crystal ball but also had some power and money with that thought, i think a couple of things. i would hope that our country would move towards

looking at families as a whole, but in a family, a mother could be depressed, for example. so if you treat her depression, you're actually helping her as a mother, do her motherly roles. oftentimes, when people are treated for mental health problems as adults, they're never asked, "are you a parent?" and we have some preventive, evidence-based practices to help people become positive in their parenting, which can affect the outcome of their children. i guess i would also say that we need to think of kids developmentally. and we know that mental health and substance abuse problems come on at different developmental stages. and the literature tells us that we have about a 2- to 4-year window between early, kind of weak signs of something wrong, to the full diagnostic criteria being met. and so, we need to intervene in that time. so, i think those are the two messages i'd suggest. i want to encourage our audience to go to our recovery month website at recoverymonth.gov, and

i want to thank the panel for such a great show. thank you for being here. thank you. our pleasure. k yo for a copy of this program or other programs in the road to recovery series, call samhsa at 1-800-662-help or order online at recoverymonth.gov and click on the video radio web tab. every september, national recovery month provides an opportunity for communities like yours to raise awareness of substance use and mental health problems to highlight the effectiveness of treatment and that people can and do recover. in order to help you plan events and activities in commemoration of this year's recovery month observance, the free online recovery month kit offers ideas, materials, and tools for planning, organizing, and realizing an event or outreach campaign that matches

your goals and resources. to obtain an electronic copy of this year's recovery month kit and gain access to other free publications and materials related to recovery issues, visit the recovery month website at www.recoverymonth.gov, or call 1-800-662-help. [music]